Transgender Identity and Sexuality

What is Transgender?
Transgender people are a diverse group of individuals who cross or transcend culturally defined categories of gender. Typically, sex is assigned at birth, most often based on genital appearance, Gender identity (one’s inner sense of being a boy/man or girl/ woman) is usually congruent with one’s assigned sex. However, transgender people show us that this is not always the case: Their gender identity may vary significantly from their sex assigned at birth. Transgender people include transsexuals (those who desire or have had hormone therapy or surgery to feminize or masculinize their body); crossdressers (those who wear clothing associated with the other sex and/or spend part of the time in the other gender role); drag queens and kings (those who combine hyperfemininity with hypermasculinity, usually for entertainment); and other individuals who may describe themselves as bigender or two-spirit (both man and woman), gender questioning (especially common among youth), gender variant or gender queer (who are people challenging gender norms in various ways).
How Common Is It?
The prevalence of transgenderism is largely unknown in part due to the associated stigma. Online studies indicate that the prevalence of transgenderism may be as high as 1 in every 50 people. More specifically, the prevalence of transsexualism (based on applicants for sex reassignment) has been estimated at 1 in every 11,900 for male-to-female reassignment and 1 in every 30,400 for female-to-male (Kesteren, Gooren, & Megens, 1996). It is unknown why male-to-female transsexuality is more common than female-to-male (Olsson & Moller, 2003).

What Causes Someone to Grow Up to Be Transgender or Transsexual?
The existence of transgender people has been documented throughout times and across cultures (Feinberg, 1996). For example, Chevalier D’Eon was a famous male-to-female transgender person in 18th century France, and Jack Bee Garland, a popular writer in San Francisco around the turn of the 20th century, was born female yet lived for most of his life as a man. Research on the etiology of transgenderism has explored both biological and environmental determinants (Cohen-Kettenis & Gooren, 1999). Findings point toward the role of biology via sexual differentiation of the brain influenced by hormones and genes, but evidence to date indicates that biology cannot fully explain the development of gender variance (Segal, 2006). Social and cultural factors, such as early life experiences and rigid gender norms, may also play a role.

What Is Gender Dysphoria and How Is It Treated?
Transgender individuals may experience discomfort with their sex assigned at birth (male or female) and gender role (living as a man or woman). They may have a desire to feminize or masculinize their body and/or change their gender role. When this discomfort is strong, the individual might meet criteria for a diagnosis of Gender Identity Disorder (American Psychiatric Association, 2000. Treatment options include psychotherapy, changes in gender role, hormone therapy, and breast/chest and genital reconstructive surgery. For those who are seeking physical changes, treatment of this disorder is guided by Standards of Care set forth by the World Professional Association for Transgender Health (Meyer et al., 2001).

How Effective Is Sex Reassignment?
Sex reassignment involves a change in gender role from male to female or female to male, hormone therapy, surgery, and a change in sex on identification documents. Transgender individuals’ perceived satisfaction with sex reassignment ranges from 87% among male-to-females to 97% among female-to-males. Predictors of satisfaction include younger age at time of reassignment, participation in psychotherapy, and family support. Dissatisfaction has been associated with inadequate surgical results. Regrets and reversal to the original gender role are rare (less than 2%; Pfaefflin & Junge, 1998).

What Does Research Tell Us About the Transgender Coming-Out Process?
Many transgender individuals experience intense stigma for their gender nonconformity and transgender expression. Verbal harassment, physical violence, employment and housing discrimination are not uncommon (Bockting & Avery, 2005). Nevertheless, transgender individuals are currently coming out earlier in life, developing pride in transgender identity, and more successfully changing gender roles in the community and on the job than in the past. Coming out involves acknowledgement of transgender feelings to self and others, exploring identity and community, finding an authentic gender presentation, deepening intimacy, and, eventually, integrating one’s transgender identity into the overall sense of self (Bockting & Coleman, 2007). Family and friends go through their own coming out process, moving through stages of denial, shock, anger, fear, and loss toward eventual acceptance of their transgender loved one. As a result of stigma and discrimination, transgender people are more vulnerable to developing anxiety and depression. However, support from family and peers has been shown to buffer these negative effects. Support begins with respecting a transgender person’s gender identification (e.g., by using preferred pronouns and name) and continues with open communication in an honest relationship.

What Is Known About the Sexuality and Health of Transgender People?
Transgender individuals may be attracted to men, women, or both. Discomfort with one’s body and role may compromise sexual relationships prior to sexual experimentation during the transgender coming out process (Bockting, Robinson, & Rosser, 1998). Female-to-males may experience an increase in sexual desire as a result of hormone therapy. Male- to-females may struggle with compulsive sexual behavior prior to transition, with feminizing hormones typically reducing sexual desire and making erections more difficult. However, sex continues to be important, particularly to affirm gender identity. Most, but not all transsexuals are able to achieve orgasm after genital reconstructive surgery (Lawrence, 2005). The prevalence of HIV and other sexually transmitted infections is high among marginalized subgroups of the transgender population (Herbst et al., 2008).

What About Transgender Youth?
Gender variance, particularly among boys, may negatively impact relationships with peers and contribute to anxiety and behavior problems (Cohen- Kettenis et al., 2003). As a result of stigma and isolation, transgender youth are at increased risk for substance abuse, homelessness, and suicide. Fortunately, transgenderism has gained in visibility and more schools and communities offer Lesbian, Gay, Bisexual, Transgender (LGBT) support groups than in the past. Schools and communities should respect and accommodate the youth’s gender expression and offer protection against ridicule and violence. The Internet provides opportunities for transgender youth and their families to connect with others who are having similar experiences. The physical changes of puberty can be extra challenging for trangender youth. Those with persistent gender dysphoria are eligble for hormone therapy. In general, the younger generation appears to be less ashamed and freer to express their gender diversity than those who came before them.

What Should Be the Focus of Future Research?
Previous research has largely focused on clinical samples and demonstrated that sex reassignment is a viable and effective treatment for gender dysphoria. Research using community samples has revealed the great diversity in gender and sexuality among this population, and has begun to identify health disparities in the areas of HIV and mental health (Bockting & Avery, 2005). Future research is needed to strengthen the evidence base guiding the promotion of transgender health more broadly.

References
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.
Bockting, W. O., & Avery, E. (Eds.). (2005). Transgender health and HIV prevention: Needs assessment studies from transgender communities across the United States. Binghamton, NY: The Haworth Press.
Bockting, W., & Coleman, E. (2007). Developmental stages of the transgender coming out process: Toward an integrated identity. In R. Ettner, S. Monstrey, & E. Eyler, (Eds.), Principles of transgender medicine and surgery (pp. 185-208). New York: The Haworth Press.
Bockting, W. O., Robinson, B. E., & Rosser, B. R. S. (1998). Transgender HIV prevention: A qualitative needs assessment. AIDS Care, 10, 505-526.
Cohen-Kettenis, P. T., & Gooren, L. J. G. (1999). Transsexualism: A review of etiology, diagnosis and treatment. Journal of Psychosomatic Research, 46, 315-333.

Cohen-Kettenis, P. T., Owen, A., Kaijser, V. G., Bradley, S. J., & Zucker, K. J. (2003). Demographic characteristics, social competence, and behavior problems in children with gender identity disorder: A cross- national, cross-clinic comparative analysis. Journal of Abnormal Child Psychology, 31, 41-53.
Feinberg, L. (1996). Transgender warriors: Making history from Joan of Arc to RuPaul. Boston, MA: Beacon Press.
Herbst, J. H., Jacobs, E. D.. Finlayson, T. J., McKleroy, V. S., Neumann, M. S., & Crepaz, N. (2008). Estimating HIV prevalence and risk behaviors of transgender persons in the United States: A systematic review. AIDS & Behavior, 12, 1-17.
Kesteren, P. J. van, Gooren, L. J., & Megens, J. A. (1996). An epidemiological and demographic study of transsexuals in The Netherlands. Archives of Sexual Behavior, 25, 589-600.
Lawrence, A. A. (2005). Sexuality before and after male-to-female sex reassignment surgery. Archives of Sexual Behavior, 34, 147-166.
Meyer, W., III, Bockting, W., Cohen-Kettenis, P., Coleman, E., DiCeglie, D., Devor, H., et al., (2001). The standards of care for gender identity disorders, sixth version. Journal of Psychology & Human Sexuality, 13(1), 1-30.
Olsson, S. E., & Möller, A. R. (2003). On the incidence and sex ratio of transsexualism in Sweden, 1972-2002. Archives of Sexual Behavior, 32, 381-386.
Pfaefflin, F., & Junge, A. (1998). Sex reassignment. Thirty years of international follow-up studies after sex reassignment surgery, A comprehensive review, 1961-1991. International Journal of Transgenderism.

Segal, N. L. (2006). Two monozygotic twin pairs discordant for female- to-male transsexualism. Archives of Sexual Behavior, 35, 347-358.

Written by Walter O. Bockting, PhD